Balancing Act: Intensive Versus Standard BP Control in Hypertension Management

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New research presented at ACC.25 suggests that intensive blood pressure control reduces cardiovascular events and mortality in patients with hypertension.

Hypertension remains one of the most prevalent and modifiable risk factors for cardiovascular disease (CVD), yet optimal target ranges for blood pressure control are still debated. At the American College of Cardiology (ACC) 2025 Scientific Sessions, researchers from the State University of Maringa in Brazil presented a systematic review and meta-analysis that adds weight to the argument for more intensive blood pressure management in patients with hypertension.

Guidelines & Treatment Targets

Despite decades of research, variation persists in treatment thresholds and goals for managing elevated blood pressure. While many clinicians initiate treatment at systolic blood pressure (SBP) levels above 140 mmHg, others have adopted lower thresholds, particularly for patients with comorbidities.

“Every few years the hypertension guidelines change,” says cardiologist Mary Greene, MD. “Some years they advocate for tighter blood pressure control, other years for a less strict approach. I try to treat each patient on an individualized basis.”

The meta-analysis presented at ACC.25 analyzed data from five randomized controlled trials (RCTs) involving 26,992 patients with a mean age of 65.29 years. The trials compared outcomes between intensive BP control (SBP ≤120 mmHg) and standard control (SBP ≤140 mmHg). The authors found that intensive treatment significantly reduced the risk for several cardiovascular events, including:

• stroke (RR, 0.83)
• myocardial infarction (RR, 0.83)
• acute heart failure decompensation (RR, 0.78)
• cardiovascular mortality (RR, 0.85)
• all-cause mortality (RR, 0.85)

Importantly, these benefits extended to patients with a history of cardiovascular events. However, the researchers also found an increased risk for dizziness and syncope in the intensive group (RR, 1.38), while there was no significant difference in hypotension or bradycardia between groups.

Expert Insights & Clinical Context

According to Dr. Greene, age and frailty are crucial factors in determining appropriate blood pressure targets. “In general, we like to avoid overly aggressive lowering in older adults, especially those over 70, to prevent hypotension, orthostatic changes, and hypoperfusion,” she says.

Cardiologist George Rodgers, MD, echoes this caution. In an interview with Physician’s Weekly, Dr. Rodgers says that while lowering blood pressure has clear benefits, “the challenge lies in how low is too low. While lower BP reduces risk for heart disease and stroke, it can be dangerous for the brain, especially in older, frail patients.”

Rodgers references evolving standards in hypertension management. The JNC 8 guidelines previously advised a BP goal of less than 150/90 mmHg for patients older than 60. However, findings from the SPRINT trial and recent observational data suggest that even lower BP targets, down to 115/70 mmHg, may offer better protection against cardiovascular events.

The analysis presented at ACC.25 reinforces the clinical dilemma of finding the sweet spot between maximizing cardiovascular benefits and minimizing adverse effects. Both Drs. Greene and Rodgers emphasize the importance of individualized treatment plans.

“If I have patients on medication, I do my best to obtain at least a normalized BP—under 120/80 mmHg,” says Dr. Greene. “But it depends entirely on the clinical scenario.”

“It’s hard to generalize in medicine,” she adds. “Blood pressure management should always be tailored to the individual using both evidence and lived clinical experience.”

Patient education is another essential component. Physicians should help patients understand the rationale for their specific blood pressure goals and the importance of adherence, while also monitoring for symptoms like lightheadedness or dizziness that could indicate overcorrection.